CERTIFICATE OF LIABILITY INSURANCE (55)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY)
03113108
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Suncoast Insurance Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 2:2668 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33622-2668
813289-5200 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Travelers Indemnity Co of America 25666
Advanced Systems Engineering, Inc. INSURER B: Travelers Indemnity Company 25658
13555 Automobile Blvd. INSURER C: Travelers Casualty and Surety Co 19038
Suite 330 INSURER D: XL Specialty Insurance Company 37885
Clearwater, FL 33762 INSURER E:
Client#: 5955
ADVASYS3
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER PJ>}~f~J~~~8mIE Pg~fl,~~~t~N LIMITS
A ~NERAL LIABILITY 6606851L26A 10102107 10102108 EACH OCCURRENCE $1 000000
lL 3MMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1 000000
- CLAIMS MADE [Xl OCCUR MED EXP (Anyone person) $5 000
- PERSONAL & ADV INJURY $1 000000
- GENERAL AGGREGATE $2 000 000
GEN'L AGGREGATE LIMIT APnS PER: PRODUCTS. COMP/OP AGG $2 000 000
~ IXl PRO- .'
POLICY JECT LOC
B AUTOMOBILE LIABILITY BA4883L691 08117107 08117108 COMBINED SINGLE LIMIT
- $1,000,000
ANY AUTO REeE" (Ea accident)
- 'ED
ALL OWNED AUTOS BODILY INJURY
- (Per person) $
SCHEDULED AUTOS
- MAR 1 9 2 ~O8
2L HIRED AUTOS BODILY INJURY
$
2L NON-OWNED AUTOS (Per accident)
- OF fCIAL RECOR )$ AND PROPERTY DAMAGE
$
, /:( :f~' ^ '1"11 '''' "1"\\,. .^ - (Per accident)
=rAGE LIABILITY - -". .oJ u&;:r', AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY CUP6849Y191 08117107 08117108 EACH OCCURRENCE $5 000.000
~ OCCUR D CLAIMS MADE AGGREGATE $5 000.000
$
~ DEDUCTIBLE $
X RETENTION $ 10000 .. . - .,., $ . ,
,,". . -
C WORKERS COMPENSATION AND UB6848Y201 08117107 08117108 X I WC STATU- I IOl~'
EMPLOYERS' LIABILITY $500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $500 000
If yes, describe under E.L. DISEASE - POLICY LIMIT $500 000
SPECIAL PROVISIONS below
D OTHER Professional DPR9611360 03110108 03110109 $2,000,000 per claim
Liability $2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Professional Liability is claims made and reported.
Certificate holder is listed as an additional insured with respects to
General Liability, Auto Liability and Excess Liability policies on a
primary and non-contributory basis. Waiver of Subrogation in favor of the
(See Attached Descriptions)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL.---3Q.... DAYS WRITTEN
Attn: City Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
PO Box 4748 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
Clearwater, FL 33758-4748 REPRESENTATIVES.
A~ED REPR~TIVE
.,.". Q/... .a. ~
ACORD 25 (2001/08) 1 of 3
#M160841
KEB
@ ACORD CORPORATION 1988
IMPORT ANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
1-
ACORD 25.5 (2001/08) 2 of 3
#M160841
Q;~tRI~'IQt4"~Cont'inue"I"~~9m 'Pag~, 1)
atlditional insured applies to the General Liability, Auto Liability,
Excess .. _4
Liability and Workers Compensation policies.
AMS 25.3 (2001/08)
3 of 3
#M160841